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Advanced Practice Providers Can Improve Transperineal Biopsy Access

By: Alex J. O’Hara, APRN, CNP; Corinna Hughes, DNP, APRN; Carl Christensen, PA-C; Derek Lomas, MD | Posted on: 04 Jan 2023

The prostate biopsy is one of the most common procedures performed in urology practices throughout the United States. It has historically been performed by a urologist using a transrectal approach. While adoption of the transperineal biopsy has become increasingly popular, these procedures continue to be performed by a urologist in the United States. In the United Kingdom, nurse practitioners have been performing prostate biopsies since 1998. More recently, they have played an important role in the country’s initiative to transition to transperineal prostate biopsy.

Our department transitioned to transperineal prostate biopsy in 2019. With this transition, we experienced an increase in demand for the procedure. Up to that point, we had been performing most of our prostate biopsies under moderate sedation, as many of these were performed using MRI fusion. With increased demand for transperineal biopsy, we looked to increase biopsy access for patients. It had been a long-term goal of our department to offer transperineal biopsy with local anesthesia (LATP) in a clinic setting. As we looked to establish this clinic, we soon realized that the demand for transperineal biopsy outpaced physician availability.

Our department has seen success with implementation of advanced practice providers (APPs) performing clinic-based procedures including cystoscopy, percutaneous tibial nerve stimulation, and a myriad of men’s health procedures. With a proven track record of our APPs performing procedures and documented success in the United Kingdom with nurse practitioners performing LATP, we moved forward with developing an APP-led transperineal biopsy clinic.

Development of this clinic required a substantial team effort. Our team of APPs, consultants, nurses, technicians, and leadership worked very hard to develop a practice model and training program for APPs to safely and successfully perform LATP.

Our training begins with didactic and direct observation phases. The next step is performing biopsies under direct supervision of trained staff. Each provider’s background has been considered when mapping out the training phase. This has generally taken around 3-6 months. Training starts with didactic and hands-on experience with the ultrasound machine, MRI fusion software, and transperineal access device. We utilize a skills lab for the APP to practice on phantom prostates. This allows the provider to become more comfortable with the equipment and software. Next, the APP observes a minimum of 20 transperineal biopsies. Finally, the APP performs a minimum of 20 transperineal biopsies under direct supervision of an experienced consultant or APP. These initial biopsies are generally performed on sedated patients. The APP will transition to LATP once deemed competent by supervising providers. At the completion of training, the APP is prepared to perform both systematic and MRI fusion LATP.

Initial rollout of our APP-led LATP clinic began in late 2020. We saw immediate success with the implementation of this practice. We have been able to increase timely access for patients while preserving quality of care. This practice has allowed surgeons to focus on other aspects of surgical and clinical care beyond the APP scope of practice. Additionally, APPs performing these biopsies have all reported an increase in job satisfaction due to increased variety in their practice.

Our initial experience with this practice has also highlighted possible challenges for implementation at practices across the country. First and foremost, this type of practice requires support from all stakeholders in the practice. Consultants, administrators, and nursing should all be on board to ensure success. Another challenge to consider is that scope of practice restrictions can vary by state. APPs may be restricted from performing procedures by their state’s department of health, board of medicine, or board of nursing.

Today, our team of 3 APPs has performed close to 1,000 LATPs. We have been able to significantly increase access for patients wishing to proceed with LATP. Access has increased by over 100% for our LATP practice. Our preliminary data have shown that these biopsies can be performed safely and effectively by a properly trained APP. We look forward to publishing our finalized data in 2023.

In the future, we believe that APPs will play a greater role in optimizing the clinical pathway for prostate cancer screening.